What It Is and How To Get It Done

Scaling and Root Planing

Scaling and root planing can be a technically challenging procedure. Tenacious calculus, tortuous pockets, irregular root anatomy, and the inability of the operator to visualize the tip of the instrument during the procedure, make this one of the most demanding tasks for the general dentist, the hygienist, or the periodontist. To be performed well requires patience, persistence, and skill. Patients often do not appreciate either the value or the difficulty of a thorough scaling. Those with newly diagnosed untreated periodontitis may be accustomed to a quick rubber-cup prophylaxis and will be frustrated by the length of time required and the more likely occurrence of postoperative discomfort. Educating the patient about the value of the procedure represents an important component of this stage of care.

Conservative Photoactivated Disinfection Periodontal Therapy ()

The elimination of periodontal pathogens from the depths of the pockets promotes the gingival health far more effectively than SRP débridement alone can. Aseptim Plus periodontal therapy is clinically straightforward, simple to carry out or delegate, and an excellent adjunct to routine SRP. Used together, these treatments offer more predictable long-term clinical results.

Scaling and root planing.

Scaling and root planing constitute a central element in the periodontal component of the disease control phase. These procedures provide effective antimicrobial therapy by mechanically removing bacteria and disrupting their local ecologic niche. The primary purpose of scaling and root planing is to remove plaque and calculus from affected enamel and cementum, eliminating irregular and rough root surfaces in the process. Coupled with careful personal and professional oral hygiene procedures, such measures will help prevent subsequent plaque accumulation and disease progression. These improvements manifest clinically as reduced probing depths and lessened gingival inflammation (i.e., gingival redness and bleeding on probing).

Scaling and root planing can be a technically challenging procedure. Tenacious calculus, deep pockets, irregular root anatomy, and the inability of the operator to visualize the tip of the instrument during the procedure make this one of the most demanding tasks for the general dentist, hygienist, or periodontist. To be performed well requires patience, persistence, and skill. Patients often do not appreciate either the value or difficulty of a thorough scaling and root planing. Those with newly diagnosed untreated periodontitis may be accustomed to a quick rubber-cup prophylaxis and will be frustrated by the length of time required and the more likely occurrence of postoperative discomfort. Educating the patient about the value of the procedure represents an important component of this stage of care. A few clinical practicalities in support of these procedures serve the patient and practitioner well (see In Clinical Practice: Improving the Efficacy of Scaling and Root Planing Procedures box).

Mechanical Nonsurgical Periodontal Therapy

Mechanical nonsurgical periodontal therapy, also known as scaling and root planing or subgingival debridement, is indicated for individuals with early periodontitis and as the initial phase of treatment of moderate or advanced periodontal diseases. Scaling and root planing removes subgingival calculus and plaque, disrupts the dental biofilm, and frees the root surface of contamination from microbial byproducts. One of the most common periodontal procedures, effective nonsurgical therapy requires meticulous instrumentation of periodontal pockets. Similar results are achieved with the use of hand instruments or ultrasonic scalers.

The primary effect of mechanical nonsurgical therapy is reducing the microbial challenge. Multiple clinical studies show that nonsurgical therapy significantly decreases the number of microorganisms in subgingival plaque and alters the subgingival microbiota to decrease the likelihood of disease progression. Evidence supports the efficacy of scaling and root planing in reducing pocket depth through resolution of inflammation and stabilizing periodontal attachment levels. An important outcome of reduced probing depths is an environment that permits personal oral hygiene practices to be more effective.

Drug Class:

Tetracycline derivative for nonantibacterial use

Diabetes

Of the chronic, common, endocrine, metabolic, and inflammation-based diseases; systemic diseases; and conditions that affect the health of the periodontium, the strongest scientific evidence for the strongest effect pertains to hyperglycemia/diabetes, as per extensive literature reviews. It is often stated that diabetes is a risk factor for periodontitis. However, it is not a diabetes diagnosis per se that is the deciding factor. Rather, the degree of hyperglycemia dictates the magnitude of effect on the periodontium, as expressed by Genco in 1996: “Risk factors which we know today as important include diabetes mellitus, especially in individuals in whom metabolic control is poor.” Nonetheless, only rather recently has this important qualifier been acknowledged and reported. This dose–response effect was illustrated by a population study among 3086 Germans that demonstrated that although poorly controlled type 2 diabetes was associated with periodontitis, well-controlled diabetes and prediabetes were not. Another study reported worse periodontal parameters in participants with prediabetes compared to normoglycemia. A rare study of the effect of controlling glycemia on the peridontium found that improving glycemic control in type 2 diabetes with no accompanying periodontal treatment significantly lowered the BOP especially in those with higher baseline bleeding levels. In contrast, periodontal pocket depths did not improve.

6.2.3 In Vivo Human Studies

It should be noted that periodontitis is the most studied field of dentistry regarding the clinical application of PDT.

In , Andersen et al. compared the effectiveness of PDT with routine SRP considering the treatment of periodontitis. They assessed bleeding on probing (BOP), probing pocket depth (PPD), and clinical attachment level (CAL) at four time points. Among the different treatment modalities, the combination of SRP and PDT was revealed to be the most effective at improving the clinical parameters. In the same year de Oliveira et al. (2007) performed a split-mouth clinical trial to investigate the potential of PDT in treating aggressive periodontitis. They irradiated phenothiazine with a laser (690 nm). After 3 months there were no significant differences between the patients receiving SRP and those who underwent PDT according to the clinical parameters.

In Braun et al. assessed the efficacy of PDT as an adjunct treatment in cases with chronic periodontitis. They found that additional use of PDT after routine SRP improved clinical parameters including relative attachment level, sulcus fluid flow rate, and BOP. In another study Christodoulides et al. (2008) investigated the clinical and microbiological benefits of PDT as an adjunct to routine SRP in treatment of patients with chronic periodontitis. They found no additional benefit of single-dose PDT on clinical parameters except for BOP. In addition, the microbial changes showed no differences between the group receiving SRP and those receiving both SRP and PDT.

In Romanos and Brink performed a clinical study to compare the effectiveness of PDT with a diode laser (980 nm) and an Nd:YAG laser (1064 nm) and found significant reduction in the number of bacteria in all patients. Ruhling et al. (2010) observed that PDT with conventional ultrasonic debridement had a similar benefit on persistent periodontitis pockets with at least 4 mm of probing depth. They concluded that PDT is not a superior treatment modality and should be used in conjunction with routine mechanical treatment. Sigusch et al. (2010) performed another clinical study to evaluate the effectiveness of PDT after routine SRP in patients who had F. nucleatum in the sites with chronic periodontitis. They assessed clinical parameters including plaque index, BOP, reddening, gingival recession, probing depth, and CAL at four time points (baseline, 1, 4, and 12 weeks). They observed a significant reduction in reddening, BOP, probe depth, and attachment level in the PDT group. After 4 and 12 weeks the probing depth and attachment level in the PDT group were significantly different from those of the control group. In addition, the number of F. nucleatum was significantly lower in the 12th-week assessment in comparison to the baseline in the PDT group. They concluded that PDT is an appropriate adjunct treatment in patients with chronic periodontitis and F. nucleatum infection.

One year later, in , Campos et al. observed that adjunctive use of PDT led to significantly higher reduction in PPD and gain of CAL. In addition, the number of pockets with probing depth of more than 5 mm and positive BOP was significantly lower in the SRP + PDT group compared with SRP alone. They concluded that PDT is an appropriate adjunctive treatment and could be beneficial in the maintenance phase of periodontitis.

Periodontitis Not Responsive to Initial Therapy

As discussed in , initial therapy for periodontitis usually consists of meticulous scaling and root planing (often performed under local anesthesia); specific instruction in oral self care; and after a 6- to 8-week period, a detailed reevaluation or post—initial therapy evaluation. Although most patients respond favorably to this regimen, some do not. The causes of failure may include specific aggressive pathogenic microbes, poor oral self care, site-specific impediments to plaque and debris removal, or inadequate host response as a result of systemic factors, such as smoking or poorly controlled diabetes.

Periodontal Maintenance

Periodontitis not responsive to initial therapy

As discussed in , initial therapy for periodontitis usually consists of meticulous scaling and root planing (often performed under local anesthesia); specific instruction in oral hygiene; and, after a 4- to 8-week period, a detailed reevaluation including new periodontal charting. Although most patients respond favorably to this regimen, some do not. Others may respond well at some sites and not so well at others. The causes of failure may include specific pathogenic bacteria, poor oral hygiene, site-specific impediments to plaque and debris removal, or inadequate host response as a result of systemic factors, such as smoking or poorly controlled diabetes.

Initial Treatment of Periodontal Disease

Scaling and root planing.

Scaling and constitute a central element in the periodontal component of the disease control phase. These procedures provide effective antimicrobial therapy by mechanically removing bacteria and disrupting their local ecologic niche. The primary purpose of scaling and root planing is to remove plaque and calculus from affected enamel and cementum, eliminating irregular and rough root surfaces in the process. Coupled with careful personal and professional oral hygiene procedures, such measures will help prevent subsequent plaque accumulation and disease progression. These improvements manifest clinically as reduced probing depths and lessened gingival inflammation (i.e., gingival redness and bleeding on probing).

Scaling and root planing can be a technically challenging procedure. Tenacious calculus, deep pockets, irregular root anatomy, and the inability of the operator to visualize the tip of the instrument during the procedure make this one of the most demanding tasks for the general dentist, hygienist, or periodontist. To be performed well requires patience, persistence, and skill. Patients often do not appreciate either the value or difficulty of a thorough scaling and root planing. Those with newly diagnosed untreated periodontitis may be accustomed to a quick rubber-cup prophylaxis and will be frustrated by the length of time required and the more likely occurrence of postoperative discomfort. Educating the patient about the value of the procedure represents an important component of this stage of care. A few clinical practicalities in support of these procedures serve the patient and practitioner well (see In Clinical Practice: Improving the Efficacy of Scaling and Root Planing Procedures box).

Concomitant Periodontal Procedures

One can consider the use of guided tissue regeneration, alloplastic or allogenic bone grafting, and in conjunction with periapical surgery. In cases of severe bone dehiscence, the likelihood of success is compromised substantially and may lead to the intraoperative decision to extract the tooth. Periodontal probing before surgery often detects the presence of significant bony defects. Sometimes the amount of bone loss cannot be appreciated until a flap is removed from the area. Thus one needs to stress the exploratory nature of the surgery preoperatively with the patient.

The placement of an additional foreign body, such as a GORE-TEX membrane to an area already infected, is more likely to lead to failure of the surgery. Membrane stabilization and adequate mobilization of soft tissues to cover the membrane may increase the complexity of the surgical procedure. Non-resorbable membranes also require a second procedure for their removal that may be unacceptable to the patient and may increase scarring.

Periodontics

Generally, periodontal treatment should precede operative care, especially when improved oral hygiene and initial scaling/ procedures create (through reduction of gingival inflammation) a more desirable environment for performing operative treatment. A tooth with a questionable periodontal prognosis should not receive an extensive restoration until periodontal treatment provides a more favorable prognosis. If a tooth has a good periodontal prognosis, then operative treatment may occur before or after periodontal therapy, as long as the operative treatment is not compromised by the existing tissue condition. Treatment of deep caries lesions often requires caries control (see ). Caries control may utilize temporization, creation of a foundation, or root canal therapy/foundation before periodontal therapy. The correction of gross restorative defects in restoration contours (e.g., open contact resulting from restoration undercontour, gingival overhang, poor embrasure form, occlusal interference resulting in increased mobility) is considered a part of initial periodontal therapy, and such corrections enable a more favorable tissue response. If periodontal surgical procedures are required, indirect restorations such as inlays or onlays, crowns, and prostheses should be delayed until the surgical phase is completed. Teeth planned for cast restorations may, however, be prepared and temporized before periodontal surgery. This approach permits confirmation of the restored tooth prognosis before surgery and allows improved access for the surgical procedure.

Patients with gingivitis and early periodontitis generally respond favorably to improved oral hygiene and scaling/root planing procedures. Patients with more advanced periodontitis might require removal (or at least minimization) of associated risk factors/indicators through surgical steps that eliminate/reduce sulcular depths or various regenerative procedures to resolve their periodontal disease. Steps to increase the zones of attached gingiva and eliminate abnormal frenal tension should be achieved by corrective periodontal surgical procedures around teeth receiving restorations with subgingival margins. In addition, any teeth requiring restorations that may encroach on the biologic width of the periodontium should have appropriate crown-lengthening surgical procedures performed before the final restoration is placed. Usually, a minimum of 6 weeks is required after the surgery before final restorative procedures are undertaken.

Scaling, Curettage, and Root Planing

Scaling, Curettage, and Root Planing

Outcome

Effect of periodontal treatment on the pulp

Frenotomy and Frenectomy

A frenotomy involves an incision of the periosteal fiber attachment and possibly suturing of the frenum to the periosteum at the base of the vestibule. It is associated with less postoperative discomfort than a frenectomy and will usually suffice. A frenectomy involves complete excision of the frenum and its periosteal attachment. A frenectomy is indicated when large, fleshy frena are involved. The need for a frenectomy or frenotomy should be based on the individual’s ability to maintain gingival health. The surgical management of the abnormal maxillary labial frenum is presented in (see Figs. 3-50 to 3-52).

If a high frenum is associated with an area of no or minimal keratinized gingiva and a frenotomy or frenectomy is indicated, a gingival graft or vestibular extension should be used to augment the procedure. Under these circumstances, a frenotomy or frenectomy often does not create stable long-term results. Bohannan indicated that, if there is an adequate band of attached gingiva, high frena and vestibular depth do not pose a problem. Use of the latter procedures to accomplish elimination of the frenum pull is considered a more standard approach.

FRENOTOMY AND FRENECTOMY

A frenotomy involves incision of the periosteal fiber attachment and possibly suturing of the frenum to the periosteum at the base of the vestibule. It is associated with less postoperative discomfort than a frenectomy and will usually suffice.

A frenectomy involves complete excision of the frenum and its periosteal attachment. A frenectomy is indicated when large, fleshy frenums are involved. The need for a frenectomy or frenotomy should be based on the ability to maintain gingival health. The surgical management of the abnormal maxillary labial frenum is presented in (see Figs. 7-50 to 7-52 ).

If a high frenum is associated with an area of no or minimal keratinized gingiva and a frenotomy or frenectomy is indicated, a gingival graft or vestibular extension should be used to augment the procedure. Under these circumstances, a frenotomy or frenectomy often does not create stable long-term results. Bohannan indicated that, if there is an adequate band of attached gingiva, high frenums and vestibular depth do not pose a problem. Use of the latter procedures to accomplish elimination of the frenum pull is considered a more standard approach.

Initial Treatment of Periodontal Disease

Scaling and Root Planing

Scaling and root planing can be a technically challenging procedure. Tenacious calculus, tortuous pockets, irregular root anatomy, and the inability of the operator to visualize the tip of the instrument during the procedure, make this one of the most demanding tasks for the general dentist, the hygienist, or the periodontist. To be performed well requires patience, persistence, and skill. Patients often do not appreciate either the value or the difficulty of a thorough scaling. Those with newly diagnosed untreated periodontitis may be accustomed to a quick rubber-cup prophylaxis and will be frustrated by the length of time required and the more likely occurrence of postoperative discomfort. Educating the patient about the value of the procedure represents an important component of this stage of care.

Conservative Photoactivated Disinfection Periodontal Therapy ()

The elimination of periodontal pathogens from the depths of the pockets promotes the gingival health far more effectively than SRP débridement alone can. Aseptim Plus periodontal therapy is clinically straightforward, simple to carry out or delegate, and an excellent adjunct to routine SRP. Used together, these treatments offer more predictable long-term clinical results.

Scaling and root planing.

Scaling and constitute a central element in the periodontal component of the disease control phase. These procedures provide effective antimicrobial therapy by mechanically removing bacteria and disrupting their local ecologic niche. The primary purpose of scaling and root planing is to remove plaque and calculus from affected enamel and cementum, eliminating irregular and rough root surfaces in the process. Coupled with careful personal and professional oral hygiene procedures, such measures will help prevent subsequent plaque accumulation and disease progression. These improvements manifest clinically as reduced probing depths and lessened gingival inflammation (i.e., gingival redness and bleeding on probing).

Scaling and root planing can be a technically challenging procedure. Tenacious calculus, deep pockets, irregular root anatomy, and the inability of the operator to visualize the tip of the instrument during the procedure make this one of the most demanding tasks for the general dentist, hygienist, or periodontist. To be performed well requires patience, persistence, and skill. Patients often do not appreciate either the value or difficulty of a thorough scaling and root planing. Those with newly diagnosed untreated periodontitis may be accustomed to a quick rubber-cup prophylaxis and will be frustrated by the length of time required and the more likely occurrence of postoperative discomfort. Educating the patient about the value of the procedure represents an important component of this stage of care. A few clinical practicalities in support of these procedures serve the patient and practitioner well (see In Clinical Practice: Improving the Efficacy of Scaling and Root Planing Procedures box).

Mechanical Nonsurgical Periodontal Therapy

Mechanical nonsurgical periodontal therapy, also known as scaling and or subgingival debridement, is indicated for individuals with early periodontitis and as the initial phase of treatment of moderate or advanced periodontal diseases. Scaling and root planing removes subgingival calculus and plaque, disrupts the dental biofilm, and frees the root surface of contamination from microbial byproducts. One of the most common periodontal procedures, effective nonsurgical therapy requires meticulous instrumentation of periodontal pockets. Similar results are achieved with the use of hand instruments or ultrasonic scalers.

The primary effect of mechanical nonsurgical therapy is reducing the microbial challenge. Multiple clinical studies show that nonsurgical therapy significantly decreases the number of microorganisms in subgingival plaque and alters the subgingival microbiota to decrease the likelihood of disease progression. Evidence supports the efficacy of scaling and root planing in reducing pocket depth through resolution of inflammation and stabilizing periodontal attachment levels. An important outcome of reduced probing depths is an environment that permits personal oral hygiene practices to be more effective.

6.2.3 In Vivo Human Studies

It should be noted that periodontitis is the most studied field of dentistry regarding the clinical application of PDT.

In , Andersen et al. compared the effectiveness of PDT with routine SRP considering the treatment of periodontitis. They assessed bleeding on probing (BOP), probing pocket depth (PPD), and clinical attachment level (CAL) at four time points. Among the different treatment modalities, the combination of SRP and PDT was revealed to be the most effective at improving the clinical parameters. In the same year de Oliveira et al. (2007) performed a split-mouth clinical trial to investigate the potential of PDT in treating aggressive periodontitis. They irradiated phenothiazine with a laser (690 nm). After 3 months there were no significant differences between the patients receiving SRP and those who underwent PDT according to the clinical parameters.

In Braun et al. assessed the efficacy of PDT as an adjunct treatment in cases with chronic periodontitis. They found that additional use of PDT after routine SRP improved clinical parameters including relative attachment level, sulcus fluid flow rate, and BOP. In another study Christodoulides et al. (2008) investigated the clinical and microbiological benefits of PDT as an adjunct to routine SRP in treatment of patients with chronic periodontitis. They found no additional benefit of single-dose PDT on clinical parameters except for BOP. In addition, the microbial changes showed no differences between the group receiving SRP and those receiving both SRP and PDT.

In Romanos and Brink performed a clinical study to compare the effectiveness of PDT with a diode laser (980 nm) and an Nd:YAG laser (1064 nm) and found significant reduction in the number of bacteria in all patients. Ruhling et al. (2010) observed that PDT with conventional ultrasonic debridement had a similar benefit on persistent periodontitis pockets with at least 4 mm of probing depth. They concluded that PDT is not a superior treatment modality and should be used in conjunction with routine mechanical treatment. Sigusch et al. (2010) performed another clinical study to evaluate the effectiveness of PDT after routine SRP in patients who had F. nucleatum in the sites with chronic periodontitis. They assessed clinical parameters including plaque index, BOP, reddening, gingival recession, probing depth, and CAL at four time points (baseline, 1, 4, and 12 weeks). They observed a significant reduction in reddening, BOP, probe depth, and attachment level in the PDT group. After 4 and 12 weeks the probing depth and attachment level in the PDT group were significantly different from those of the control group. In addition, the number of F. nucleatum was significantly lower in the 12th-week assessment in comparison to the baseline in the PDT group. They concluded that PDT is an appropriate adjunct treatment in patients with chronic periodontitis and F. nucleatum infection.

One year later, in , Campos et al. observed that adjunctive use of PDT led to significantly higher reduction in PPD and gain of CAL. In addition, the number of pockets with probing depth of more than 5 mm and positive BOP was significantly lower in the SRP + PDT group compared with SRP alone. They concluded that PDT is an appropriate adjunctive treatment and could be beneficial in the maintenance phase of periodontitis.

Periodontitis Not Responsive to Initial Therapy

As discussed in , initial therapy for periodontitis usually consists of meticulous scaling and (often performed under local anesthesia); specific instruction in oral self care; and after a 6- to 8-week period, a detailed reevaluation or post—initial therapy evaluation. Although most patients respond favorably to this regimen, some do not. The causes of failure may include specific aggressive pathogenic microbes, poor oral self care, site-specific impediments to plaque and debris removal, or inadequate host response as a result of systemic factors, such as smoking or poorly controlled diabetes.

Periodontal Maintenance

Periodontitis not responsive to initial therapy

As discussed in , initial therapy for periodontitis usually consists of meticulous scaling and (often performed under local anesthesia); specific instruction in oral hygiene; and, after a 4- to 8-week period, a detailed reevaluation including new periodontal charting. Although most patients respond favorably to this regimen, some do not. Others may respond well at some sites and not so well at others. The causes of failure may include specific pathogenic bacteria, poor oral hygiene, site-specific impediments to plaque and debris removal, or inadequate host response as a result of systemic factors, such as smoking or poorly controlled diabetes.

Regeneration

Most clinical studies comparing laser with standard therapy in the treatment of periodontitis use scaling and as the control treatment, rather than conventional surgical procedures. The concept of regeneration of the periodontal attachment apparatus as an ultimate goal in the treatment of periodontitis is an end point for which clear data are lacking regarding long-term retention of the dentition. The debate will continue over the regenerated connective tissue attachment versus the long junctional epithelial attachment resulting from many surgical and nonsurgical periodontal procedures. For purposes of comparison, however, laser procedures appear to be conducive to regeneration by decreasing bacteria, affecting root surfaces, removing granulation tissue, and deepithelializing the sulcular lining, as previously suggested.

However, when laser therapies are compared with conventional open-flap procedures, with or without the addition of biologic mediators such as enamel matrix protein derivatives, the conclusions are consistent in that no statistical or clinically significant differences have been found between open-flap procedures and laser-mediated periodontal surgeries.

In a human histologic study, use of an Nd:YAG laser to remove sulcular epithelium resulted in formation of new cementum and new connective tissue attachment, whereas a control group of patients exhibited development of a long junctional epithelium with no evidence of regeneration. Moreover, no adverse changes were described in the laser group. This report suggests a laser-assisted new attachment procedure for the treatment of chronic periodontitis. Of interest, the study did not use stents to aid in clinical measurements. Although manual probing is susceptible to variation, the results achieved nevertheless fall within the range of acceptable measurement error for probing depth and clinical attachment levels of ±1 mm reported in other clinical trials. A justifiable conclusion, therefore, is that these two parameters may merely be equal to those observed with scaling and root planing.

Schwarz et al. treated naturally occurring periodontitis in beagle dogs with an erbium laser or with an ultrasonic power-driven device. Both treatment groups exhibited new cementum formation with embedded collagen fibers. The investigators concluded that both therapies supported the formation of new connective tissue attachment. Many other researchers (e.g., Rossmann, Israel, Froum, Cettny) have shown the CO₂ laser’s ability to create a new connective tissue attachment, rather than a long junctional epithelium. CO₂ laser manufacturers have received FDA clearance under the 510(K) rule, showing equivalence to the laser-assisted new attachment procedure.

Again, technique in periodontal surgery for periodontitis depends on whether the clinician chooses to alter only soft tissue or both soft and hard tissue. Accurate pocket depth charting, radiographic evaluation, establishment of mobility patterns, and measurements of attached gingiva are required before all procedures.